THE BIHAR TIMES
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Mental Health In A Public Health Perspective

 

Mental health is undeniably one of our most precious possessions to be nurtured, promoted and preserved as best as we can. It is the state of mind in which the individual can experience sustained joy of life while working productively, interacting with others meaningfully and facing up adversity without losing capacity to function physically, psychologically and socially. It is undoubtedly a vital resource for a nation’s development and its absence represents a great burden to the economic, political and social functioning of the nation.

*Anant Kumar,
Rehabilitation Psychologist

Understanding Mental Health

Mental health is among the more important public health issues. Defining health as physical, mental and social well being, A.V. Shah (1982) has expressed that mental health is "the most essential and inseparable component of health…. An integrated component of public health and social welfare programmes…."

Going by the World Health Organization’s definition of health, couple of words draw our attention heavily. Words like ‘ physical’, ‘mental’ and ‘social’ force us to ponder more and more, more than the boundaries of biomedical model which addresses only physical ailments, that too not comprehensively (in the word biomedicine ‘real’ disease). There are number of dimensions, which contribute to positive health like, spiritual, emotional, vocational, philosophical, cultural, socio-economic, environmental, educational and nutritional besides the physical, mental and social dimension. Thus, health is multidimensional. Although these dimensions function and interact with one another, each has its own nature.

Perhaps the easiest dimension of health to understand is ‘physical’, which is nothing but biomedical definition of health. Mental health is not mere absence of mental illness. Good mental health is ability to respond to many varied experiences of life with flexibility and a sense of purpose. More recently mental health has been defined as "A state of balance between the individual and the surrounding world, a state of harmony between oneself and others, coexistence between the realities of the self and that of other people and that of the environment". On the other hand, social well being implies harmony and integration within the individual, between each individual and other members of society and between individuals and the world in which they live (Park, 1995). It has been defined as the "quantity and quality of the individual’s interpersonal ties and the extent of involvement with the community (Donald, 1978).

The social dimension of health includes the levels of social skills one possesses, social functioning and the ability to see oneself as a member of a larger society. Social health is rooted in "positive material environment" (focusing on financial and residential matters), and "positive human environment" which is concerned with the social network of the individual (Fillenbaum, G.G., 1984).

On the outset, these definitions and explanations of social and mental components of health look similar. But they have sharp differences, which need to be understood for a clear analysis of these dimensions.

In larger sense, mental health or mental dimension refers to the inner harmony of an individual but social component of health refers to the external harmony of an individual. The way one adjusts with his residential and financial matters. Mental dimension looks at how one solves his internal conflicts, the level of self-esteem, his needs, problems and goals and ability to strike a balance between rationality and emotionality.

A few decades ago, the mind and body were considered independent entities. Recently however, researchers have discovered that psychological factor which can induce all kinds of illnesses, not simply mental ones. They include conditions such as essential hypertension, peptic ulcer, and bronchial asthma (WHO 1964 Technical Report Series, 275).

India’s Mental Health Scenario

In the past and in the present also, in the field of health, our mind has been preoccupied with communicable diseases because they are the biggest causes of death in the population. These diseases have partly been conquered. We have been looking at health in terms of physical health, while neglecting mental health. Over the years, mental illness has increased manifold. Although there has been a demographical study, psychiatrist estimates that about two percent of Indians suffer from mental illness, a staggering 20 million out of a population of 100 million. A recent survey of 500 working women in Delhi by Hamara Parivar, a family welfare programme, has found that 78 % of them suffer from depression due to sociological pressures and breakdown of personal relationships.

Epidemiological surveys done in India as well as in many other parts of the world have amply confirmed that at any given time one to two percent of the population suffers from serious mental illnesses. While 10 to 15 percent suffers from so-called mental disorders like anxiety, depression, fear, obsession, somatic symptoms due to tension, alcohol and drug abuse etc. Women seem to be more prone to anxiety and depression while men to alcohol and drugs more often. One to two percent of Indians suffers from manic-depressive illness alone. Nine million people have schizophrenia in India (one out of 1000).

Bhargavi V. Davar in her book "Mental Health of Indian Women -A feminist Agenda" says that the presence of distress is estimated to be about fifteen percent of the entire population, this is only a part of the truth. Davar examines data from various studies to conclude that common mental illnesses are more common among women than in men. Even feminists have been largely silent on mental distress in women. While mental health professionals have sidestepped the issues of gender and social problems, Davar’s analysis of desegregated data proves that marriage in Indian society is probably the single most important cause of distress to middle class women, as she says, "Marriage is a stressful occupation for women". She feels that mental distress may be a good indicator of social stress and justice.

The number of mental health professionals in the country is limited. The variations across state are enormous. For example, Kerala (with a population of 30 million) has over 300 psychiatrists while Madhya Pradesh (with a population of 70 million) has only 31 psychiatrists and 300 psychiatric beds. In addition, the implementation of the NMHP has had an initial spurt, with delays in expansion. The development of support materials and models at the district level facility for initiating and coordinating the large-scale expansion of the mental health programme is a serious problem.

Mental Health Policies in India

Health policies and programmes have significant role in shaping health services system and care. It is evident from the report of all committees that in the field of mental health, our achievements are not satisfactory. Although all the committee reports emphasize the need to improve the mental health services with its various recommendations, there is no serious attempt to improve mental health services in India. In this context, the National Mental Health Programme (1982) was a major development in providing mental health care through different methods as well as overall goals of health care in general.

Before Independence, there were no clear strategies for the care of mentally ill. The approach was largely to build ‘asylums’ which were for custodial care rather than therapeutic or rehabilitation centers. Pre -Independence situation according to Bhore Committee: "Even if the proportion of mental patients are taken as two per in 1,00 crore population in India, hospital accommodation should be available for at least 2 crore mental patients, as against the existing provision of a little over 10,000 beds for the country as a whole. In India, the ratio of one bed to about 40,000 population, while in England, the corresponding ratio is approximately one bed to 300 population."(GOI 1946).

The Mudaliar Committee reviewed the progress made in mental health, subsequent to the Bhore Committee, over a period of nearly two decades, in the following words: "Reliable Statistics regarding the incidence of mental morbidity in India is not available. It is believed that an enormous number of patients require psychiatric assistance and service… There is hardly any provision for the education of mental defectives. Provision for the treatment of psychosomatic diseases in general hospitals are inadequate."(GOI 1962)

In the curative field, the committee recommended the setting up of in-patient and outpatient departments at lay hospitals, independent psychiatric and mental health clinics, and institutions for the mentally ill.

Active thinking in the area of mental health marked the decade of the seventies. The Srivastava Committee (1974) recommended that one hour (out of the total training of 200 hours of community health workers) be devoted to mental health. In addition, one manual of the community health workers would deal with the recognition and management of mental health emergencies and problems.

In 1983, the National health policy suggested a "special well-coordinated programme should be launched to provide mental health care as well as medical care, and also the physical and social rehabilitation of those who are mentally retarded, deaf, dumb, blind, physically disabled, infirm and the aged." (GOI 1983)

The National Mental Health Programme

The national Mental Health programme (GOI 1982) is the outcome of the various initiatives taken to provide mental health care through different methods. It aims at providing mental health care to the population utilizing the available resources.

The Central Council of Health and Family Welfare has recommended that mental health should form an integral part of the total health programme, and should be included in all National policies and programmes on health, education and social welfare.

As decided in the meeting of the Central Council of Health in 1995 and as recommended by the Workshop of all the Health Administrators of the Country held in February, 1996, the District Mental Health Programme was launched in 1996-97 in four Districts, one each in Andhra Pradesh, Assam, Rajasthan and TamilNadu with a grant assistance of Rs. 22.5 Lakhs each. A budgetary allocation of Rs. 28.00 Crores has been made during the Ninth Five Year Plan for the National Mental Health Programme.

The training to the Trainers at the State level is being provided regularly by the National Institute of Mental Health and Neuro Sciences, Bangalore under the National Mental health Programme. The District Mental Health programme was extended to seven Districts in 1997-1998, five Districts in 1998 and 6 Districts 1999-2000. Thus, this programme is under implementation in 22 Districts in 20 States.

(Source: Ministry of Health & Family Welfare.)

 

Need for Realistic Programmes

The above discussion clearly signifies that mental health is an important component of health and development of the human society. Despite various recommendations and policies, the development of mental health services has been uneven. Since Independence, various committees have recommended policies to conduct epidemiological survey to generate base-line epidemiological data and information system for the development of mental health services. But till date, we are dependent on estimates that vary regionally and mostly generated on the basis of hospital admissions and discharge. A similar lag has been noticed in the implementation of the Mental Health Act, in spite of the fact that it was accepted by the parliament in 1987 and became operational since April 1993.

It is necessary on the part of public health personnel to conduct research in bringing out the epidemiological basis for such programmes. Responsibilities also lie with the social scientists to influence the government and public health work in order to have a broader view and better understanding for the problems related to mental health. In the Indian context, no proper research has been done to see the ways in which culture and religion influence mental illnesses and health. It is also clear that mental illness is a significant cause of disability in India, which has been largely ignored, in health related development activities. The impact of economic structural adjustment in impoverishing people, the breakdown of traditional community and family relationships caused by urban migration, and the myriad adverse effects of newer diseases like AIDS are likely to cause a greater impact on people’s psychosocial health. In addition, these programmes do not incorporate proper preventive measures, even curative and rehabilitative services provided are inadequate in terms of the estimated needs.

The development of support materials and models at the district level facility for initiating and coordinating the large-scale expansion of the mental health problem is a serious problem. These programmes lack in-built evaluation mechanism, having no space for continuous research and community participation at the functional level. The absence of a central organization for mental health has been a serious constraint in post Independence planning in India. Twenty out of twenty-five States have not set up The State Mental Health Authority, as in March 1996.

There have been innovative initiatives in the private sector in a number of areas of mental health. The most notables of these are crisis intervention, rehabilitation of the mentally ill, and care of the elderly and street children. However, this has mostly been at the local level, without adequate evaluation and expansion to cover the rest of the country. In this context, voluntary organizations should be given greater importance, and encouraged to participate to a greater in mental health care programme.

There are number of new issues that have come up in the country with implication for mental health. The most notable are alcohol policies, violence in society, the growing population of elderly persons, urbanization, mental health of women, disaster care, migrants and refugees, street children, and stress at the work place. These issues have to be tackled by mental health professionals, since such cases do not reach hospitals and clinics but have impact on society, if not adequately addressed on time.

References:

  1. Bhargavi, V. Davar 1999 Mental Health of Indian Women- A Feminist
  2. agenda.

  3. WHO, 1964 Technical report series, 275.
  4. Park 1995 Parks textbook of preventive and social medicine, Banarsidas
  5. Bhanot publishers, New Delhi.

  6. Independent Commission on Health on India, VHAI New Delhi, India.
  7. Government of India report, A Report 1946, 1962, and 1982.
  8. Fillenbaum, G.G, 1984. The Well being of the elderly, WHO offset
  9. publication 84.

  10. Shah A.V.(1982).Integration of mental health, Indian Journal of

Psychiatry, 24,3-7

 

 

Anant Kumar, a Rehabilitation Psychologist and Research Scholar, is with the Centre of Social Medicine and Community Health, School of Social Sciences, Jawaharlal Nehru University, New Delhi – 110067. (Email: pandeyanant@bihartimes.com)